Operation Surf Final Technical Report and Summary...Data were first entered into excel to generate the PTSD Checklist for DSM-5 (PCL-5), Beck Depression Inventory II (BDI-II) and General

The Impact of Ocean Therapy on Veterans with Posttraumatic Stress Disorder

By Russell Crawford, PhD.

Final Technical Report and Summary

Data Analysis and Results

Introduction

Posttraumatic stress disorder (PTSD) often prevents individuals from re-assimilating to

civilian life due to a disconnect between their own experiences with war and the experiences of

others, often leading individuals with PTSD to have difficulties with relationships and increased

risk seeking or illegal behaviors (Hauffa et al., 2011; Myrseth et al., 2012). With the increase in

PTSD cases in the United States in the last 15 years (Rogers et al., 2014), there is a constant

motivation for mental health agencies in the United States to seek therapeutic activities for

individuals with PTSD that do not involve pharmaceuticals, alcohol, or illegal drugs (Rogers et

al. 2014), particularly for combat veterans.

The purpose of this quantitative study was to determine the effect of nature-based

therapy, an alternative form of treatment that focuses on the interaction of the individual and the

environment, on combat veterans with PTSD. The focus was to determine if the therapy reduced

PTSD symptoms, decreased depression and increased self-efficacy among veterans. This was

done by expanding on the work of Rogers et al. (2014) examining the effect of ocean therapy, a

type of nature-based therapy that primarily uses surfing as the treatment modality (Nichols,

2014; Rogers et al., 2014). Combat veteran subjects were sought who were about to begin an

ocean therapy program, and their PTSD, depression and self-efficacy were measured using

online surveys prior to the commencement of the therapy. The same veterans were surveyed

using the same surveys at the end of the program and also 30 days after the program. This

chapter firsts presents summary statistics of the collected data at each time point and then

repeated-measures ANOVAs to answer the research questions and hypotheses. The chapter is

concluded with a summary.

Descriptive Data

Data were first entered into excel to generate the PTSD Checklist for DSM-5 (PCL-5),

Beck Depression Inventory II (BDI-II) and General Self-Efficacy Scale (GSE) scores for each

subject. All participants in Amazing Surf Adventure’s Operation Surf program were eligible to

participate. Both men and women between the ages of 20 and 55 participated in this study. All

participants were military combat veterans. A total of 113 subjects were contacted for

participation, and 95 subjects responded to the survey. All 95 subjects completed all parts of

each survey at three time periods. No demographic data were collected. Data were then entered

into SPSS for summary statistic generation and assumption testing. Assumption tests for

repeated measures ANOVA include that the dependent variable is a continuous variable, that the

independent variable is a marker which denotes how subjects have been measured on two or

more occasions on the same dependent variable (i.e., a marker for time), that there are no

significant outliers in the data, that the dependent variable is approximately normally distributed,

and that sphericity is present within the data, i.e., there is homogeneity of variance (Green &

Salkind, 2014). These assumptions were tested for each research question; violations of the

assumptions resulted in further testing and/or corrective action.

Mean and standard deviations of scores for each of the variables at each time point is

presented in Table 1 and Table 2. Both PCL-5 and BDI-II have the highest mean values at the

first time point before the commencement of therapy (52.18 and 45.05 respectively).

Immediately after finishing the therapy program both scores are almost half their previous values

(22.99 and 26.44 respectively), although at the third time point 30 days after therapy both scores

have risen although not as high as their initial values (42.72 for PCL-5 and 34.87 for BDI-II).

This is presented graphically in Figures 2 and 3. Self-efficacy shows the opposite pattern, as the

mean score is the lowest prior to the commencement of the program (17.33) and increases

immediately after the program (35.61). There is a drop in GSE score after the 30-day period

(31.93), but it is not as large as the change between time points two and three for PTSD and

depression. In order to determine whether or not these differences between time points are

statistically significant, repeated measures ANOVA tests were run on the data. Results of the

ANOVA checks are discussed later in this chapter.

Table 1 Summary Statistics of PTSD Checklist for DSM-5 (PCL-5), Beck Depression Inventory II (BDI-II) and General Self-Efficacy Scale (GSE) Scores at Each Time Point

Variable

Time 1 M (SD)

Time 2 M (SD)

Time 3 M (SD)

PCL-5 Score 52.18 (2.90) 22.99 (3.34) 42.72 (4.20)

BDI-II Score 45.05 (5.39) 26.44 (6.01) 34.87 (6.81)

GSE Score 17.33 (3.22) 35.61 (3.40) 31.93 (4.40)

Table 2 Means, Standard Deviations, and Study Variables

Variable M SD Min. Max.

General Self-Efficacy, Time 1 17.33 3.22 12 25



Beck Depression Inventory, Time 1 45.05 5.39 31 58



PTSD Checklist for DSM-5, Time 1 52.18 2.90 46 59



Note. n = 95.

Figure 2. Boxplots showing PTSD Symptoms as Measured using the PCL-5 score at each time point. Time point 1 = before therapy, time point 2 = immediately after therapy and time point 3 = 30 days after therapy.

Figure 3. Boxplots showing Depression Symptoms as Measured using the BDI-II score at each time point. Time point 1 = before therapy, time point 2 = immediately after therapy and time point 3 = 30 days after therapy.

Figure 4. Boxplots showing Self Efficacy as Measured using the GSE score at each time point. Time point 1 = before therapy, time point 2 = immediately after therapy and time point 3 = 30 days after therapy.

Data Analysis Procedures

All data analysis was conducted in SPSS 23. Repeated measures ANOVA for each of

PCL-5 scores, BDI-II scores and GSE scores were done using the time point of the survey as the

independent variable. Analysis was completed by first testing the assumptions of repeated

measures ANOVA mentioned previously. Specifically, the first assumption requires that the

dependent variable be continuous in nature. This assumption was met for all dependent variables

(i.e., PCL-5 score, BDI-II score and GSE score), as all dependent variables were measured as

aggregated scales. The second assumption requires that the independent variable in a repeated

measures ANOVA be a marker which denotes how subjects have been measured in two or more

time points on the same dependent variable. This assumption was met, as subjects were

measured before therapy, immediately after therapy and 30 days after therapy. The third

assumption is that there are no significant outliers in the data. This assumption was checked for

each repeated measures ANOVA via a visual inspection of the box and whiskers plot. The fourth

assumption is the dependent variable is approximately normally distributed. This assumption

was checked for each repeated measures ANOVA via the Shapiro-Wilk test. Finally, the fifth

assumption is that sphericity is present within the data, i.e., there is homogeneity of variance.

This assumption was checked for each repeated measures ANOVA via Mauchly’s test of

sphericity. Any violations of the final three assumptions (i.e., outliers, normality and sphericity)

resulted in further testing and/or corrective action for each repeated measures ANOVA that was

computed for each of the three research questions.

Results of the repeated measures ANOVA tests were then subjected to post-hoc testing

using pairwise comparisons with Bonferroni corrections as a way to determine the exact

relationships between variable levels if the ANOVA was significant. This analysis was done in

the event of a statistically significant ANOVA result to determine what time points were

statistically different from each other. Repeated measures ANOVA was the most appropriate

statistical test as it allows for one to determine if there was a significant relationship between the

time a survey was taken and the score of that survey, while taking into account repeated

measurements from each subject. Post hoc-testing allowed one to identify which time points had

significantly different scores in surveys.

Prior to all statistical analyses, several steps were taken to prepare the data.

Several variables were constructed from original data so as to effectively model each variable in

question; namely, self-efficacy, depression, post-traumatic stress levels, and sports motivation.

The scales that measured self-efficacy at time 1, time 2 and time 3 were created as the sum of the

ten scale items for the General Self-Efficacy Scale. For example, self-efficacy at time 1 was

created as the sum of the ten scale items measured at time 1. The same logic was used at time 2

and time 3. The scales that measured depression at time 1, time 2 and time 3 were created as the

sum of the twenty-one scale items for the Beck Depression Inventory Scale. For example,

depression at time 1 was created as the sum of the twenty-one scale items measured at time 1.

The same logic was used at time 2 and time 3. The scales that measured PTSD at time 1, time 2

and time 3 were created as the sum of the twenty scale items for the PCL-5 Scale. For example,

PTSD at time 1 was created as the sum of the twenty scale items measured at time 1. The same

logic was used at time 2 and time 3. If the variable of time taken of the survey was found to be

significant, post-hoc testing was used to identify which pairwise comparisons of time were

significantly different using Bonferroni corrections for multiple comparisons.

Results

Results are presented in order of research question. All 95 subjects were used for each

analysis.

RQ1: Is there an increase in self-efficacy among veterans who participate in ocean therapy

as measured by the GSE at Time 1, Time 2, and Time 3?

H01: There is no increase in self-efficacy among veterans who participate in ocean therapy

at Time 1, Time 2, and Time 3.

H1: There is an increase in self-efficacy among veterans who participate in ocean therapy


As previously noted, the first and second assumptions of a repeated measures ANOVA

(that the dependent variable is continuous and that the independent variable denotes how subjects

have been measured in two or more time points on the same dependent variable) have been met

for the first research question. Testing for the third assumption of normality was accomplished

by using the Shapiro-Wilk test. Results showed that the self-efficacy data was significantly non-

normal at time point 1 (0.934 (95), p < 0.001), time point 2 (0.926 (95), p < 0.001) and time

point 3 (0.932 (95), p < 0.001). Even though this test was statistically significant, the violation of

this assumption is not considered to be an issue for the current statistical analysis, as ANOVA is

known to be robust against deviations from normality, provided that sample size is more than 30

(Schmider, Ziegler, Danay, Beyer, & Bühner, 2010).

Table 3 Tests of Normality for GSE

Shapiro-Wilk

Statistic df Sig.

GSEScaleT1: General Self- Efficacy Scale, Time 1

.934 95 .000


.926 95 .000


.932 95 .000

The assumption check for statistical outliers was accomplished via a visual inspection of

the box and whisker plots for the self-efficacy scores at time 1, time 2, and time 3. Figure 5

below shows no outliers within the data for self-efficacy.

Figure 5. Boxplots showing Self Efficacy as Measured using the GSE score at each time point. Time point 1 = before therapy, time point 2 = immediately after therapy and time point 3 = 30 days after therapy.

As a repeated measures ANOVA was used, the assumption of homogeneity of variances

was tested with Mauchly’s test of sphericity instead of Levene’s test. For self-efficacy,

Mauchly’s test of sphericity was found to be non-significant (Mauchly’s W = 0.983 (2), p =

0.445), thus meeting the requirements of this assumption.

The results of the repeated measures ANOVA for the main effect of time indicated a

statistically significant change in self-efficacy over time (F (2,188) = 644.25, p < 0.001) and are

presented in Table 4. As there was a significant ANOVA result, pairwise comparisons with

Bonferroni corrections were undertaken. Pairwise results are presented in Table 5. Before

therapy self-efficacy, as measured by the GSE, was found to be significantly lower than both

time points after therapy (mean marginal difference after therapy = 18.28, mean marginal

difference 30 days after therapy = 14.60). However, there was also a significant increase in self-

efficacy from the immediately after therapy score and the score at 30 days after therapy (mean

marginal difference = 3.68). Based on these findings and the ANOVA presented above, we

concluded that there is a significant increase in self-efficacy following Ocean therapy for combat

veterans. However, it should be noted that this increase in self-efficacy is less 30 days after the

therapy.

Table 4 ANOVA Table for Self-Efficacy (GSE)

Variable

Sum of Squares df Mean Squares F Significance

Time of Survey 17766.45 2 8883.22 644.25 < 0.001

Error 2592.21 188 13.78

Table 5 Pairwise Comparisons of GSE Score at Each Time Point Using a Bonferroni Correction

Variable Comparison Mean Difference Std Error Significance

Before Therapy After Therapy -18.28 0.49 < 0.001

30 Days After -14.60 0.53 < 0.001

After Therapy 30 Days After 3.68 0.56 < 0.001

RQ2: Is there a decrease in depression in veterans who participate in ocean therapy as

measured by the BDI-II at Time 1, Time 2, and Time 3?

H02: There is no decrease in depression in veterans who participate in ocean therapy at

Time 1, Time 2, and Time 3.

H2: There is a decrease in depression in veterans who participate in ocean therapy at Time

1, Time 2, and Time 3.




for the second research question. Testing for the third assumption of normality was accomplished

by using the Shapiro-Wilk test. Results showed that the BDI-II score data were not significantly

non-normal at time point 1 (0.992 (95), p = 0.84), or time point 2 (0.991 (95), p = 0.75), but was

significantly non-normal at time point 3 (0.882 (95), p < 0.001), as presented in Table 6. Even

though this test was statistically significant at the third time point, the violation of this

assumption is not considered to be an issue for the current statistical analysis, as ANOVA is


(Schmider et al., 2010).

Table 6 Tests of Normality for BDI-II

Shapiro-Wilk

Statistic df Sig.

BECKSCaleT1: Beck Depression Scale, Time 1

.992 95 .845


.991 95 .749


.882 95 .000


the box and whisker plots for depression scores at time 1, time 2, and time 3. Figure 6 below

shows some outliers within the data for depression at time 3, the most concerning being the very

high value and the very low value. For ANOVA the effect of outliers is that they lower the

chance of rejecting the null hypothesis, in other words they lower the chance of finding a

significant result due to the increase in variance of the mean. No changes were made, but

interpretation of the results should be made with these outliers in mind.

Figure 6. Boxplots showing Depression Symptoms as Measured using the BDI-II score at each time point. Time point 1 = before therapy, time point 2 = immediately after therapy and time point 3 = 30 days after therapy.


was tested with Mauchly’s test of sphericity instead of Levene’s test. For depression, Mauchly’s

test of sphericity was found to be statistically significant (Mauchly’s W = 0.861, df = 2, p <

0.001), thus suggesting heterogeneity of variance. In this situation, it is recommended that either

the Greenhouse-Geisser correction or the Huynh-Feldt correction be applied to the data analysis

(Girden, 1992). Of the two choices, the Huynh-Felt correction is the preferred technique when

epsilon is greater than 0.75. For depression scores, epsilon for the Greenhouse-Geisser was

0.884, and for the Huynh-Feldt correction, epsilon was 0.910. As such, the Huynh-Felt

correction was applied to the repeated measures ANOVA results. ANOVA analysis determined

there was a significant effect of the time point that the BDI-II was taken at on BDI-II (F (2, 188)

= 188.99, p < 0.001) and is presented in Table 7.

Table 7 ANOVA Table for Depression (BDI-II)

Variable


Time of Survey 16500.04 1.78 9237.19 188.99 < 0.001

Error 8206.61 167.90 48.87

As there was a significant effect of time of survey on BDI-II score, post hoc testing was

conducted to determine which comparisons were significantly different using a Bonferroni

correction. All pairwise comparisons were found to be significantly different even with the

outliers, as presented in Table 8. The before therapy BDI-II score was found to be significantly

higher than both time points after therapy (mean difference with after therapy = 18.61, mean

difference with 30 days after therapy = 10.17). The mean BDI-II score 30 days after therapy was

also found to be significantly lower than the mean BDI-II score immediately after therapy (mean

difference = 8.43). Based on these findings and the ANOVA, we reject the null hypothesis and

accept that there is a significant reduction in depression symptoms, as measured by the BDI-II

score, for combat veteran’s immediately after Ocean therapy and at the 30-day time point.

However, the reduction in depression symptoms is significantly less 30 days after therapy than

the reduction experience immediately after therapy.

Table 8 Pairwise Comparisons of BDI-II Score at Each Time Point Using a Bonferroni Correction


Before Therapy After Therapy 18.61 0.87 < 0.001

30 Days After 10.17 0.85 < 0.001

After Therapy 30 Days After -8.43 1.12 < 0.001

RQ3: Is there a decrease in PTSD symptoms among veterans who participate in ocean

therapy as measured by the PCL-5 at Time 1, Time 2, and Time 3?

H03: There is no decrease in PTSD symptoms among veterans who participate in ocean

therapy at Time 1, Time 2, and Time 3.

H3: There is a decrease in PTSD symptoms among veterans who participate in ocean





for the third research question. Testing for the third assumption of normality was accomplished

by using the Shapiro-Wilk test.

Results showed that the PCL-5 score data were significantly non-normal at time point 1

(0.911 (95), p < 0.001), time point 2 (0.875 (95), p < 0.001), and time point 3 (0.969 (95), p =

0.022). Even though this test was statistically significant at all three time points, the violation of

this assumption is not considered to be an issue for the current statistical analysis, as ANOVA is


(Schmider et al., 2010).

Table 9 Tests of Normality for PCL-5

Shapiro-Wilk

Statistic Df Sig.

PCLScaleT1: PCL-5 PTSD Scale, Time 1 .911 95 .000




the box and whisker plots for PTSD scores at time 1, time 2, and time 3. Figure 7 below shows

only a single potential outlier within the data for PTSD at time 1 and time 3, but based on how

close this outlier is to the other data it was not considered of statistical concern.

Figure 7. Boxplots showing PTSD Symptoms as Measured using the PCL-5 score at each time point. Time point 1 = before therapy, time point 2 = immediately after therapy and time point 3 = 30 days after therapy.


was tested with Mauchly’s test of sphericity. For PCL-5, Mauchly’s test of sphericity was found

to be statistically significant (Mauchly’s W = 0.776, df = 2, p < 0.001), thus suggesting

heterogeneity of variance. In this situation, it is recommended that either the Greenhouse-

Geisser correction or the Huynh-Feldt correction be applied to the data analysis (Girden, 1992).

Of the two choices, the Huynh-Felt correction is the preferred technique when epsilon is greater

than 0.75. For PCL-5 scores, epsilon for the Greenhouse-Geisser was 0.783, and for the Huynh-

Feldt correction, epsilon was 0.802. As such, the Huynh-Felt correction was applied to the

repeated measures ANOVA results.

The results of the ANOVA for the effect of time indicated a statistically significant

change in PTSD symptoms over time (F (2, 188) = 2040.7, p < 0.001). As there was a significant

effect of time of survey on PCL-5 score, post hoc testing was conducted to determine which

comparisons were significantly different using a Bonferroni correction. All pairwise comparisons

were found to be significantly different, as presented in Table 11. The before therapy PCL-5

score was found to be significantly higher than both time points after therapy (mean difference

with after therapy = 29.18, mean difference with 30 days after therapy = 9.46). The mean PCL-5

score 30 days after therapy was also found to be significantly lower than the mean PCL-5 score

immediately after therapy (mean difference = 19.72). Based on these findings and the ANOVA,

we reject the null hypothesis and accept that there is a significant reduction in PTSD symptoms,

as measured by the PCL-5 score, for combat veteran’s immediately after Ocean therapy and at

the 30-day time point. However, the reduction in PTSD symptoms is significantly less 30 days

after therapy than the reduction experience immediately after therapy.

Table 10 ANOVA Table for PTSD (PCL-5)

Variable


Time of Survey 42138.96 1.65 25393.77 2040.7 < 0.001

Error 1941.032 155.98 12.44

Table 11 Pairwise Comparisons of PCL-5 Score at Each Time Point Using a Bonferroni Correction


Before Therapy After Therapy 29.18 0.46 < 0.001

30 Days After 9.46 0.36 < 0.001

After Therapy 30 Days After -19.72 0.56 < 0.001

Summary

The purpose of this quantitative study was to determine the effect of nature-based therapy

on combat veterans with PTSD by measuring PTSD symptoms, depression symptoms and self-

efficacy before commencement of Ocean therapy, after finishing the therapy and also 30 days

after finishing the therapy. There were no outliers in the data or subjects that failed to complete

all rounds of surveys that may have had an impact on quality of statistical analysis. Differences

were assessed qualitatively using repeated measures ANOVA analysis. There was found to be a

significant effect of time point of survey on GSE score (F (2,188) = 644.25, p < 0.001), BDI-II

score (F (2, 188) = 188.99, p < 0.001) and PCL-5 score (F (2, 188) = 2040.7, p < 0.001). BDI-II

and PCL-5 were both found to decrease significantly after the initial time point, and GSE score

was found to increase significantly after the initial time point. As such, the null hypothesis for all

research questions was rejected. The significance of these results will be discussed in detail in

Chapter 5.

Summary, Conclusions, and Recommendations

Introduction and Summary of the Findings

There are an estimated 2.6 million Armed Forces Americans that have participated in

various wars since 2001, with many of them returning home with injuries associated with

traumatic brain issues, and musculoskeletal malfunctions, along with amputations, as well as

stress (Radomski & Brininger, 2014). Even without a physical injury, a veteran could develop

mild to severe cases of PTSD and PTSD symptoms, which could create daily dysfunction and the

need for treatment to improve quality of life and well-being (Radomski & Brininger, 2014).

Ocean therapy is a recently developed therapy used to treat veterans with PTSD in the US due to

the ability to improve and enhance self-efficacy, as well as reduce PTSD symptoms and

depression (Nichols, 2014; Rogers et al., 2014). It is a type of nature-based therapy that primarily

uses surfing as the treatment modality, along with group programs to support the therapy using

surfing and the camaraderie that comes along with these group activities (Nichols, 2014: Rogers

et al., 2014).

In this particular study, a surf program developed by Van Curaza was used. This program

is titled Operation Surf and is executed through Amazing Surf Adventures. This program is

unique in that it is a curriculum based program that focuses on the veteran learning to surf and

connecting with other veterans with PTSD. Operation Surf is a six-day program in which

veterans are paired with current and former professional surfers who bond with the participants

and keep them safe while going out in the water together, primarily to ride the waves and enable

the veterans to successfully experience surfing with all the thrills, confidence and exuberance.

More specifically, Operation Surf begins with the arrival of veterans at the designated

hotel where participants will stay six nights and live amongst each other, the volunteers, and the

surf instructors. The first evening, participants meet at a hotel meeting room for a welcoming

and introductions. This meeting is a dinner tin which members of Operation Surf are introduced

to the veterans and the veterans introduce themselves to everyone. After dinner, wetsuits and

other materials are handed out and dry-land surf instruction takes place. In this instruction

participants are introduced to the basics of surfing and how to paddle and stand up on the board.

Following the instruction, participants check into their rooms for the evening.

The next morning the participants meet to eat breakfast together and begin the first

surfing lesson at 8:00AM. Each participant is paired with experienced surf instructors as well as

volunteers to ensure a positive experience as surfing is a challenging sport to learn. Surfing

continues through the morning hours until lunch. Lunch is served on the beach where the

veterans are able to discuss what they experienced while in the Ocean and begin to socialize with

each other. After lunch, surfing resumes with instructors and volunteers aiding all participants.

Surfing for the day ends at 2:00PM at which time participants and instructors socialize. After a

short rest, participants meet in the hotel lobby and are bused to dinner at local restaurants. The

participants continue this schedule for the next four days. Upon completion of day five, the

participants and all volunteers and instructors attend a closing ceremony to celebrate their

accomplishments over the past week. Ocean therapy, specifically Operation Surf uses the

environment as a tool to allow interaction in a new event, encouraging self-empowerment,

adventure, and happiness.

The purpose of the study was to determine if this ocean therapy is related to increased

self-efficacy, reduced PTSD symptoms and lower depression levels in veterans with PTSD in the

United States, as well as motivation. The quantitative study used repeated-measures to determine

specific outcomes related to these issues using a sample population of veterans from Santa Cruz,

California, Pismo Beach, California, and Coco Beach, Florida. The study expanded on a Rogers

et al. (2014) study that evaluated the impact of ocean therapy on veterans who were experiencing

PTSD symptomology, but was limited by the small sample size of 14 participants, along with

only investigating PTSD and depression. This study offered further understanding and filled the

gap by broadening the sample and by including the relationship between ocean therapy programs

and the self-efficacy of the veterans who could to undergo this ocean therapy.

From an original sample of 113 veterans who participated in an ocean therapy program

presented by the organization Amazing Surf Adventures, 95 clients responded to the survey and

completed all parts of the survey at each collection time, before, immediately after, and 30 days

after ocean therapy. Data were collected on three occurrences using SurveyMonkey. The three

collection points included: first, prior to participation in the therapy program, second, after

participation in the program, and third, at 30 days after participation in the ocean therapy

program. The collected data were analyzed using repeated-measures ANOVA for three separate

repeated measures. After collection, the data were first entered into excel to generate the PTSD

Checklist for DSM-5 (PCL-5), Beck Depression Inventory II (BDI-II) and General Self-Efficacy

Scale (GSE) scores for each subject. No demographic data were collected. Data were then

entered into SPSS for summary statistic generation and assumption testing.

Study results identified that both PCL-5 and BDI-II had the highest mean values at the

first collection point before the therapy began (52.18 and 45.05 respectively). Immediately after

finishing the therapy program, both scores were almost half their previous values (22.99 and

26.44 respectively), although at the third data collection point 30 days after therapy, both scores

had increased, close to the initial values (42.72 for PCL-5 and 34.87 for BDI-II). These values

and changes demonstrated that both PTSD symptoms and depression were improved

immediately after the therapy program, and slightly improved 30 days after the program.

Improvement was evident by expressed feelings of less stress, reduced anger, and a sense of

calm. Self-efficacy, the belief of the veteran to complete the therapy goals and tasks, showed the

opposite pattern which is what was desired, as the mean score was the lowest prior to the

beginning of the therapy program (17.33) and increased immediately after 30 days of the

program (35.61). There was a drop in GSE score after the 30-day period (31.93), but it is not as

large as the change between Time 2 and 3 for PTSD and depression. This demonstrated that self-

efficacy increased from before participation in the program to after participation in the program,

and there was limited change 30 days after the program when compared to participation

immediately after the program.

Summary of Findings and Conclusions

The quantitative study addressed the following research questions, using the General

Self-Efficacy Scale or GSE (Schwarzer & Jerusalem, 1995); the BDI or Beck Depression

Inventory II (Beck et al., 1996); and the PTSD Checklist for DSM-5 to measure PTSD symptom

severity (Weathers et al., 2014), along with the hypothesis reflected beneath to determine the if

ocean therapy impacts PTSD, depression, and self-efficacy.

Research Question One. R1: Is there an increase in self-efficacy among veterans who

participate in ocean therapy as measured by the GSE at Time 1, Time 2, and Time 3? The two

hypotheses were:

H01: There is no increase in self-efficacy among veterans who participate in ocean therapy


H1: There is an increase in self-efficacy among veterans who participate in ocean therapy


Outcome. After ANOVA analysis, it was determined that there was a significant effect of

the time point that the GSE was taken on (F (2,188) = 644.25, p < 0.001). The significance of the

ANOVA analysis required that pairwise comparisons with Bonferroni corrections were

undertaken to account for the number of comparisons taken. Self-efficacy before ocean therapy

as measured by the GSE, was found to be significantly lower than both time points after therapy

(mean marginal difference after therapy = 18.28, mean marginal difference 30 days after therapy

= 14.60). However, there was also a significant increase in self-efficacy from the immediately

after therapy score and the score at 30 days after therapy (mean marginal difference = 3.68).

After a review of these findings and the ANOVA results, it was concluded that there was a

significant increase in self-efficacy following ocean therapy for combat veterans. However, this

increase in self-efficacy is less 30 days after the therapy, but still significantly higher than before

the program

Research Question Two. R2: Is there a decrease in depression in veterans who

participate in ocean therapy as measured by the BDI-II at Time 1, Time 2, and Time 3?

H2: There is a decrease in depression in veterans who participate in ocean therapy at Time

1, Time 2, and Time 3.

H02: There is no decrease in depression in veterans who participate in ocean therapy at

Time 1, Time 2, and Time 3.

Outcome. ANOVA analysis determined there was a significant effect of the time point

that the BDI-II was taken at on BDI-II (F (2, 188) = 188.99, p < 0.001). Since there was a

significant effect of time of survey on BDI-II score, post hoc testing was conducted to determine

which comparisons were significantly different using a Bonferroni correction. Given that, all

pairwise comparisons were found to be significantly different, with the before ocean therapy

BDI-II score found to be significantly higher than both time points after therapy (mean

difference with after therapy = 18.61, mean difference with 30 days after therapy = 10.17). The

mean BDI-II score 30 days after therapy was also found to be significantly lower than the mean

BDI-II score immediately after therapy (mean difference = 8.43).

Due to these findings and the ANOVA results, the null hypothesis was rejected and we

accepted that there was a significant reduction in depression symptoms, as measured by the BDI-

II score, for combat veteran’s immediately after ocean therapy and at the 30-day time point.

However, the reduction in depression symptoms is significantly less 30 days after therapy than

the reduction experience immediately after therapy.

Research Question Three. R3: Is there a decrease in PTSD symptoms among veterans

who participate in ocean therapy as measured by the GSE at Time 1, Time 2, and Time 3.

H1: There is a decrease in PTSD symptoms among veterans who participate in ocean


H01: There is no decrease in PTSD symptoms among veterans who participate in ocean


Outcome. The results of the PCL-5 score (F (2, 188) = 2040.7, p < 0.001), were greatly

influenced by the time of the survey. Since there was a significant effect of time of survey on

PCL-5 score, post hoc testing was conducted to determine which comparisons were significantly

different using a Bonferroni correction. All pairwise comparisons were found as significantly

different. The before therapy PCL-5 score was found as significantly higher compared to both

time points after therapy (mean difference with after therapy = 29.18, mean difference with 30

days after therapy = 9.46). The mean PCL-5 score 30 days after therapy was also found to be

significantly lower compared to the mean PCL-5 score immediately after therapy (mean

difference = -19.72).

Due to these factors and the ANOVA analysis, the null hypothesis was rejected and this

researcher accepted that there was a significant reduction in PTSD symptoms, based on the PCL-

5 score measurement, for combat veteran’s immediately after ocean therapy and at the 30-day

data collection point. However, the reduction in PTSD symptoms was significantly less 30 days

after therapy compared to the reduction experience immediately after therapy.

Interpretation of the Findings

Self-efficacy. Research question one asked if there was an increase in self-efficacy

among veterans who participated in ocean therapy as measured by GSE and the three different

data collection times. Research revealed that self-efficacy is based on not only belief, but the

development of necessary skills and influences a person's life in every area (Bandura,1995). Self-

efficacy before ocean therapy as measured by the GSE, was found to be significantly lower than

both time intervals after therapy. However, there was also a significant increase in self-efficacy

immediately after therapy and at 30 days after therapy, concluding that there was a significant

increase in self-efficacy following ocean therapy for military veterans. However, the increase in

self-efficacy is less 30 days after the therapy. These results identify the effectiveness of ocean

therapy as a short-term solution for self-efficacy and veterans. The study contributes to the

knowledge of self-efficacy and PTSD since there are limited studies on the topic. Similar short-

term results were determined by Oman and Bormann's (2015) study about the management of

PTSD and self-efficacy of 132 veterans with weekly review for a period of six weeks.

Depression. Research question two inquired if there was a decrease in depression in

veterans who participated in ocean therapy as measured by the BDI-II at each time interval.

Research spotlighted no significant decrease in depression after participation in ocean therapy,

however earlier studies have identified a link between PTSD and depression disorders. The link

between PTSD and major depressive disorder (MDD)was an underlying theme in multiple

studies. Pukay-Martin et al. (2012) identified that the link between these issues was a concern in

their study of Afghanistan, Iraq, and Vietnam veterans. The self-reported assessment highlighted

that the development of both of these conditions was associated with higher rates of suicidal

ideation, particularly when depression was significant (Pukay-Martin et al., 2012). The same

connection was identified in Debeer et al. (2014). Maguen et al. (2012) also highlighted a strong

correlation between killing and suicide of military veterans with the suggestion that the

combination of PTSD, depression, and substance abuse resulted in suicidal ideation. PTSD and

depression were closely tied to Runnals' et al. (2013) study that evaluated the connection

between PTSD, MDD, and musculoskeletal pain with a review of almost 2,000 veterans from

2005 to 2010. Study results determined that there was a strong connection between veterans with

PTSD and MDD that reported higher pain levels. Ramsawh et al. (2014) was another study that

evaluated the tie between depression and PTSD, both separately and jointly of using the PTSD

checklist or PCL for assessment. The evaluation of over 5,000 patients resulted in the veterans

experiencing feelings of suicide between 25 percent and 29 percent, respectively for each

condition independently, but when the veteran has both conditions, the percentage of suicidal

likeliness increased to 45% (Ramsawh et al., 2014). In this study, it was anticipated that

depression would be reduced at the same rate as the PTSD symptoms due to the comorbidity of

the two, but results show a greater relief of PTSD symptoms than depression. This appears to be

an area for further inquiry.

Decreased PTSD symptoms. The goal of research question three was to determine if

there was a decrease in PTSD symptoms among veterans who participated in ocean therapy as

measured by the GSE at Time 1, Time 2, and Time 3. The study highlighted a significant

reduction in depression symptoms, as measured by the BDI-II score, for combat veteran’s

immediately after ocean therapy and at the 30-day time point. However, the reduction in

depression symptoms was significantly less 30 days after therapy than the reduction experience

immediately after ocean therapy. Also based on the PCL-5 score measurement, for combat

veteran’s immediately after ocean therapy and at the 30-day data collection point there was a

significant reduction in PTSD symptoms. However, the reduction in PTSD symptoms is

significantly less 30 days after ocean therapy than the reduction experienced immediately after

therapy. This suggested that ocean therapy is successful at various intervals and due to the

finding, it should be used on a more regular basis for sustained and ongoing results. The Rogers

et al. (2014) suggested that PTSD symptoms were improved in a small group of veterans using

ocean therapy, but warranted a larger sample size and better program evaluation. Caddick and

Smith (2014) investigated the use of ocean therapy and outdoor physical activities and military

veterans in the United Kingdom. Their study highlighted the feelings of suffering release that

occurred from the therapy and the nature environment using various forms of physical water

activities (Caddick & Smith, 2014).

PTSD has a variety of symptoms leading to comorbidity conditions of alcohol and drug

abuse, despair, feelings of hopelessness and shame, and job problems, as well as relationship

issues, along with physical violence towards friends and family (Javidi & Yadollahie, 2012).

Historically, veterans with PTSD symptoms were believed to have avoided social settings due to

increased feelings of arousal and amplified responses when startled (Hauffa et al., 2011; Myrseth

et al., 2012). Symptoms such as relationship conflicts with a spouse are believed to be associated

with PTSD, evidenced by greater aggression towards a partner and the dissolution of marriage

(Monson et al., 2009). The sharing of military experiences in discussion was found to relieve the

PTSD symptoms associated with relationship stress in Balderrama-Durbinet al. (2013).

Reduction of PTSD symptoms was also associated with other alternative treatment approaches.

Hollifield (2011) identified a reduction in PTSD symptoms with the use of acupuncture, along

with Strauss et al. (2011), which conducted a twelve-week study of acupuncture administration

biweekly for roughly 60 minutes. Reduced symptoms were sustained when a follow-up was

conducted 24 months after the initial treatment (Strauss et al., 2011).

Mindfulness-based stress reduction or MBSR is another alternative therapy that has been

tried with PTSD diagnosed veterans. Kearney et al. (2012) investigated the approach with

veterans with results that indicated there was a moderate impact for PTSD depression, when

meditation was used with mantras, evidenced by greater calm and peacefulness. Nature-based

therapies use programs with activities conducted in nature settings, such as gardening

(Stigsdotter et al., 2010). Stigsdotter's et al. (2010) research showcased the healing effects

associated with stress related mental disorders and nature-based therapies, but the effects were

not sustained long-term like in this ocean therapy study, thus suggesting future sessions are

needed to sustain reduced PTSD symptoms.

Implications

The current study sheds light on the use of ocean therapy to treat veterans with PTSD and

PTSD symptoms, particularly in the immediate and short-term capacity. Benefits of ocean

therapy provided a reduction in aggression and stress, which reduces incidences of this type of

behavior on family and friends, and provides a sense of well-being for the veteran. Healthcare

providers and organizations that deal with veterans and PTSD are encouraged to add ocean

therapy as a program practice, alongside other alternative approaches. Harnessing the power of

the need for adrenaline exhibited by many veterans, without the use of medications, has huge

appeal to sustaining the quality of life for the veteran and their family. Ocean therapy is a great

approach to addressing PTSD relief in the short-term, as well as the potential of long-term with

repeated event outings of ocean therapy. The current literature review did not reveal any

traditional approaches that were used in conjunction with ocean therapy. However, Nicholas

(2014) and Rogers et al. (2014) suggested that the therapy could be used as a practice addition.

Theoretical implications. Theoretically the study advanced on the research of Rogers et

al. (2014) by identifying the use of ocean therapy as an immediate and short-term use to address

PTSD, PTSD symptoms, depression, and self-efficacy. This was evident by the improvement in

scores, both immediately and temporarily. With increased ad hoc testing, the null-hypotheses

were rejected and resulted in increased identification of ocean therapy benefits. Study results

suggested that the use of a sports-oriented therapy intervention with traditional treatments has the

promise to treat veterans with PTSD, if the veteran has an interest in radical sports or can

develop an interest in these types of sports activities. The transition from combat to everyday life

can be challenging and complex for veterans and establishes the need for creative and effective

interventions. Ocean therapy offers the connection and merger of surfing and the veterans' past

experiences to develop greater social connections, alongside the need for an adrenaline rush,

ultimately resulting in an alternative experience that can be life changing (Adler et al., 2009;

Hoge, 2011). The study utilized the theoretical framework in the literature of self-efficacy. The

study added to the body of research with an increased sample size and demonstrated short-term

results, which can improve the outlook of veterans suffering from issues associated with PTSD.

Practical implications. Practical implications include short-term benefits of reducing

issues associated with PTSD. Increased practice use of ocean therapy with existing traditional

and alternative treatments can potentially create long-term sustainability of well-being for

veterans with PTSD. Incorporating a sports-oriented treatment program as part of a practice is an

option to treat PTSD veterans who have symptoms, depression, and who have issues coping with

life after the military, as well as have needs to engage in behaviors with risk. High intensity

sports such as surfing are socially acceptable activities that veterans can learn to reduce PTSD.

Programs of this nature can provide transition support after military life. Further studies are

required to support the use of these types of high intensity programs as a stand-alone treatment or

paired with medication and / or talk therapy

Future implications. Ocean therapy provides goal oriented activities that establish

feelings of self-efficacy in a noncombat setting. The findings from this quantitative study suggest

that sports-oriented therapy interventions show promise and merit further investigation,

specifically programs associated with high intensity sports such as surfing. Future examination

of the effectiveness of multiple types of sports interventions such as kayaking and rock climbing

may be valuable. Adapting programs of this type to enable veterans with cognitive and physical

disabilities to participate should also be evaluated as an alternative to existing programs, as well

as to be used in conjunction with existing approaches.

Limitations of the Study

The study used data collected before ocean therapy, immediately after therapy, and 30

days after therapy. While these intervals have substantial value for improved outcomes in the

short term, greater follow-up is needed to understand the sustaining ability beyond the 30-day

window. Additional review is required after 30 days to gain a better understanding of the benefits

of ocean therapy at six months, one year, and up to five years. The study size was small although

larger than previous studies such as Rogers et al. (2014), 95 participants was still a small group

versus the estimated 84% of individuals diagnosed as suffering from PTSD and PTSD symptoms

(Javidi & Yadollahie, 2012). The execution of the study was purposeful and methodical with

data collection and management, as well as analysis and instruments used. The survey tool used

yielded more than a 50% return of participants, while adequate and greater than existing studies,

needs to be further evaluated to gain greater participation. The implementation of the study used

standard tools for a study of this nature.

Recommendations for Future Research

Ocean therapy could be studied at a greater length to fully gauge the success of the

approach for long-term use. Although successful in the immediate and short-term, it may not

sustain the veteran for the amount of time needed to reduce or eliminate PTSD and PTSD

symptoms. Group and individual sessions need to be conducted both in the short-term and long-

term to increase self-efficacy and balance the need for adrenaline seeking activities. Perhaps the

inclusion of family and friends in the sessions needs to be studied, as this increases

communications about the veteran's military and ocean therapy experiences. Larger sample sizes

need to be used, as well as studies of longer durations need to be considered and performed. The

incorporation of ocean therapy to be used in conjunction with traditional and other alternative

therapies could be further studied to identify potential benefits. There may also be value in

collecting and analyzing demographic date to determine if there are any significant factors with

age, physical condition, years in service, experiences in combat, gender, family structure and

more that determine how a participant respond to ocean therapy. Another area of focus could be

how the number of participants within each Operation Surf program could influence the data

collected. Would smaller groups provide a more intimate bonding experience that would have

longer lasting results? A qualitative study of the participant’s experience would be useful to

understand why the changes occur and to better understand what would be more beneficial for a

longer lasting result.

Recommendations for Future Practice

The purpose of this quantitative study was to determine the effect of nature-based therapy

on combat veterans with PTSD by measuring PTSD symptoms, depression symptoms and self-

efficacy before commencement of ocean therapy, after finishing the therapy and also 30 days

after finishing the therapy. Differences were assessed quantitatively using repeated measures

ANOVA analysis. Significant effects were discovered at the time point of survey on GSE score

(F (2,188) = 644.25, p < 0.001), BDI-II score (F (2, 188) = 188.99, p < 0.001) and PCL-5 score

(F (2, 188) = 2040.7, p < 0.001). BDI-II and PCL-5 scores were both found to decrease

significantly after the initial time point, and GSE scores were found to increase significantly after

the initial time point. As such, the null hypothesis for all research questions was rejected.

Researchers have demonstrated that PTSD is comorbid with major depressive disorder

and substance abuse disorders which have been linked to high rates of suicide attempts and

suicide (Javidi & Yadollahie, 2012). Evidence-based treatments are available, but only a few

veterans who are diagnosed with PTSD or PTSD symptoms, get treatment due to existing

military culture, stigma, and lack of access to mental health care. Evidence-based treatments for

veterans with PTSD have included medication and cognitive-behavioral therapy, prolonged

exposure therapy, and cognitive processing therapy, which is particularly effective for treating

female victims of traumatic sexual events, and veterans and active duty members with trauma

related to war activities, as well as survivors of significant car accidents (Holliday et al., 2014).

Stress inoculation therapy and eye movement desensitization and reprocessing are considered

successful PTSD treatment methods (Gates et al., 2012). Providing more treatment options for

veterans could increase the number of veterans who seek treatment.

Veterans with PTSD frequently seek experiences and activities that provide an adrenaline

rush (Rogers et al., 2014). Research and this study support that ocean therapy can be a substitute

for illegal adrenaline oriented behaviors, as well as extreme aggressive and physical behaviors at

various intervals in the life of these patients. Surfing like other extreme sports, produces an

adrenaline rush and suggests that programs designed with this type of group activity can be

highly affective and can be introduced when needed to relieve PTSD symptoms and increase

self-efficacy, as well as reduce depression.

The findings of this study combine all of these elements and demonstrate and explain the

benefits of ocean therapy for veterans with PTSD, both immediately and short-term, as well as

potential long-term benefits if participation is ongoing. The study was guided by Bandura’s

(1977; 1986; 1997) self-efficacy theory, and ocean therapy enhanced self-esteem, and had a

positive impact on PTSD veterans. The increase in self-efficacy in veterans upon completion of

ocean therapy is significant in that high self-efficacy allows the veteran to feel as they are in

charge of the direction of their life whereas most entered the program with low self-efficacy.

Veterans with low self-efficacy feel the victim of circumstances and are more likely to

withdrawal from society and engage in self-destructive behaviors. With the increase in self-

efficacy the veteran looks at life with possibilities instead of dread.

The benefit of ocean therapy for PTSD-diagnosed veterans had a calming and meditative

impact, which has ramifications for better quality of life, improved relationships, and decreased

depression and PTSD symptoms. It is recommended that ocean therapy be incorporated into

future practices as an alternative or in conjunction with other approaches. High intensity sports

such as surfing are socially acceptable activities that veterans can learn to reduce PTSD.

Programs of this nature can provide transition support after military life. Further studies are

required to support the use of these types of high intensity programs in practices.

Documents

Operation Surf Final Technical Report and Summary...Data were first entered into excel to generate the PTSD Checklist for DSM-5 (PCL-5), Beck Depression Inventory II (BDI-II) and General